Foreign bodies of the hand. Foreign bodies Metallic foreign bodies of the skin

Foreign bodies are objects that have penetrated from the outside into any part of the body. The nature and size of foreign bodies, the ways of their introduction and localization are different. Needles, pieces of wood, glass, wire usually accidentally fall into the palmar surface of the hand, the plantar surface of the foot. In the tissues, thighs, buttocks, a part of the needle that broke when. With firearms and knife wounds bullets, shot, fragments of metal, particles of clothing, earth are introduced into the fabric. Needles, bullets, glass fragments, pieces of wire and other sharp foreign bodies through a puncture of the chest wall or the walls of the esophagus, they can penetrate into the pericardium and even into. During operations in the cavities and tissues of the body, sometimes instruments, gauze napkins, drainage tubes. Bones, pins, hairpins, nails, usually fall into and. They are swallowed accidentally or intentionally (). From the stomach, foreign bodies descend along the digestive tract and can linger in any part of the intestine. Foreign bodies are also introduced into the rectum through the anus.

In many cases, foreign bodies are encapsulated and long time are not clinically evident. Usually, foreign bodies lie motionless at the site of introduction, and the opinion that they wander in the human body is not justified. Foreign bodies can move in the thickness of the muscles during their contraction, due to gravity fall down in the purulent cavity, move through the intestines under the influence of peristalsis.

Almost all foreign bodies are infected and can cause abscess formation, outbreaks. Supporting inflammatory process they interfere with wound healing. Sometimes in the old postoperative scar an abscess is formed or does not heal for a long time, upon opening which, along with the pus, the ligature leaves. Being located in the joint, a foreign body can cause a violation of its function, near nerve trunks- pain, numbness. The pressure of a foreign body on can lead to the formation of a vessel and bleeding.

For the diagnosis of foreign bodies great importance has a carefully collected history, taking into account the nature of the injury, as well as giving an idea not only of the localization of foreign bodies, but also of its relationship with surrounding organs. With a fistula, fistuloeraphy can help to recognize foreign bodies (see). The presence of foreign bodies can be indicated by a painful induration near the wound, hematoma, and skin detachment.

Foreign bodies are removed according to strict indications, since often the search for it and the difficulties associated with removal lead to more serious violations than the presence of foreign bodies. Foreign bodies that cause disorders of the functions of vital organs (larynx, perforation of a hollow organ, bleeding, intestinal obstruction) are subject to emergency removal.

Removal of just introduced foreign bodies under the skin and easily palpable can be performed by a paramedic; deeply located foreign bodies are removed only by a doctor.

At primary processing wounds try to remove all foreign bodies (see). Foreign bodies deeply stuck in the tissues are removed if they cause significant functional disorders exert pressure on blood vessels and nerves. With multiple foreign bodies (cases of shot wounds), it is far from always possible to remove them all and one has to limit oneself to removing those that are visible or cause the most pain and dysfunction.

Indications for late removal of foreign bodies may be: suppuration of the wound supported by foreign bodies, fistula formation, repeated bleeding, pain. Before the operation, a prophylactic dose (1500 AU) of tetanus toxoid is administered. After the operation, the introduction is shown.

Most foreign bodies of the esophagus and stomach pass unhindered into the intestines and, without causing damage, come out naturally. Patients with foreign bodies of the gastrointestinal tract are subject to observation in the hospital. Laxatives are strictly prohibited. To facilitate the advancement of a foreign body, food containing a lot of vegetable fiber is prescribed. The passage of a foreign body through the intestines is controlled radiographically. It is necessary to monitor to make sure that the foreign body comes out.

Surgical intervention to remove foreign bodies from the stomach is taken in cases where the size and shape of the foreign body preclude the possibility of its advancement (an open penknife, a spoon handle, a fork, etc.), with a long delay of a foreign body in the pylorus area and signs of impaired evacuation from the stomach. With a long delay of a foreign body in the intestine, most often in the area of ​​​​the Bauhinian valve, with the appearance of signs and intestinal obstruction, a laparotomy is indicated.

Some people often complain that they constantly feel some kind of pebble in the foot that does not disappear anywhere. And shoes are not at all to blame here, because this "pebble" is actually Morton's neuroma.

The reasons

Morton's neuroma is a benign growth in the foot that occurs in the region of the nerves that innervate the human foot. It occurs most often between the bases of the 3rd and 4th fingers. The disease most often occurs on one leg, but it is very rare to find the same formation on the second foot.

Most often, this disease is diagnosed in women. In men, this is a rarity. And the main reason here is flat feet, in which nerve compression occurs. metatarsal bones. The same can be seen with the constant wearing of high-heeled shoes with a narrow nose, when the foot, or rather, the toes, are strongly squeezed throughout the day. Another reason is a fracture of the fingers or the formation of a hematoma after a bruise at the site of the nerve.

Much less often, the cause of a tumor becomes when they are literally clogged with cholesterol plaques and blood cannot flow through them normally. In some cases, long running or walking can also be the cause, during which there is a large load on the arch of the foot.

Symptoms

At the very beginning of the disease, patients complain of constant feeling numbness and pain in the foot. In addition, when wearing narrow and tight shoes, as well as shoes with high heels, there is severe discomfort. The same is noted during long walks on foot or jogging. Another diagnostic symptom which helps to make the correct diagnosis is a strong and sharp pain when squeezing the foot with your hands. And another sign is the feeling of a foreign body in the area of ​​neuroma formation.

The pain that occurs during a long walk is especially strong. But a simple foot massage will help here. However, this will not get rid of the disease itself and the next time everything will happen again.

These symptoms may either increase or disappear completely, and this alternation may last for a long time. The neuroma gradually grows and compresses the nerve more and more. And this means that soon the pain will become permanent, regardless of what shoes a person walks in. When making a diagnosis, it is necessary to exclude other diseases, such as arthritis or a fracture. To make a correct diagnosis, it is worth an x-ray examination or MRI.

Therapy

If the disease occurs in mild form, then it is better to use conservative therapy, that is, treatment with drugs. The most important thing is to eliminate pressure on the nerve, which causes severe pain. In the treatment of Morton's neuroma, it is worth using the following methods:

1. Change of shoes. It is worth wearing only shoes or shoes that do not squeeze your fingers and have a wide toe.
2. After consultation, it is better to purchase orthopedic insoles or orthopedic shoes with special instep supports.
3. Decrease pain worth trusting medicines eg use ibuprofen, ketorolac.

If these drugs do not help and the pain torments a person constantly, then you should think about the use of glucocorticosteroids. However, you cannot prescribe such drugs on your own. In most cases, such treatment at the very beginning of the disease gives a good result.

Treatment of a neuroma folk remedies unable to cure the very cause of the disease - the presence benign tumor. However, some natural preparations can reduce pain while walking or running. Bandages with mug of wormwood are perfect for this. To warm the affected area, you can use a compress of fat and salt. But before you begin to be treated in this way, you must always consult with your doctor.

Operation

If conservative methods do not give the desired result, then they resort to surgical removal of the neuroma. The operation is performed under local anesthesia and does not take much time. The operation is less traumatic and the next day a person can begin to walk independently. But this is only possible when using special insoles. However, we must remember that if the provoking factors are not excluded in the future, then the disease will return again after a while. Therefore, for the prevention of the disease, it is imperative to exclude all factors that can provoke it.

From daily practice it is known that foreign bodies are often introduced into the hand. They make up 1.7% of damage. Once in the tissue, the foreign body causes a reaction from the surrounding tissues. The further course depends on the infection introduced with a foreign body and the state of the organism. If the foreign body is aseptic, it gradually encapsulates and may remain in the hand for many years. However, in the tissues surrounding the foreign body, a dormant infection often persists, and after many years a painful process may occur. Here is one of our observations.

45 year old woman N. referred to us for a consultation by a neuropathologist about right-sided plexitis, which is not inferior to a long and varied physiotherapy treatment for five years. The cause of the disease is unknown to her, at first the pains were localized in the hand, and then spread throughout the arm, shoulder and neck. A few days ago, the pain in the hand became aggravated, a swelling appeared at the base of the little finger.

On examination and palpation, it was found: cyanosis and pastosity of the skin, smoothness of the relief of the elevation of the little finger and wrist of the right hand, soreness and thickening of the fifth metacarpal bone, adhesion of soft tissues at the base of the palm, limitation of flexion, abduction and adduction of the little finger. Hyperesthesia of the skin, muscle atrophy according to the type of lesion of the ulnar nerve. With a diagnosis chronic osteomyelitis V metacarpal bone" the patient is referred for x-ray examination. X-ray diagnosis: foreign body in the thickness of the metacarpal bone, reactive osteoperiostitis.

Operation: after preparation of the skin, under local regional anesthesia, the fifth metacarpal bone was exposed by a longitudinal dorsal-lateral incision. Its periosteum is thickened, soldered to soft tissues. The bone is easily trepanned, from the bone marrow cavity, from granulation tissue Corroded needle removed. The granulations were removed, the cavity was scraped, powdered with streptocide, a deaf layer-by-layer wound suture, immobilization of the hand and forearm with a plaster cast. Healing is smooth, pain in the arm has decreased. The patient remembered that the needle went into her hand while washing clothes 25 years ago. Surgeons often have to remove metal foreign bodies from the brush: needles, pieces of wire, metal, less often bones, wooden, glass and other objects.

It is much easier to detect and clarify the location of contrasting foreign bodies during X-ray examination than to recognize non-contrasting bodies that have invaded tissues. An x-ray of the hand is obligatory in both cases, since sometimes it is possible to catch a slight shadow on the film from both a fish bone and glass or a wooden splinter. Many different methods have been proposed to clarify the localization of foreign bodies, but for the hand, the simplest and most reliable are radiography in three projections and fluoroscopy. At the same time, the point of greatest immersion of the foreign body under pressure is found, a sterile needle is brought to the foreign body, and then convenient access is determined. Therefore, the presence of a surgeon is always recommended during x-rays. A direct picture is taken in the position of the brush, corresponding to what it will have on the operating table; the second picture - in a strictly lateral projection, it gives an idea of ​​the depth of the foreign body.

Foreign bodies often linger in the metacarpus - 47%, then in the fingers - 36.8%, less often in the wrist - 10.1%. Occasionally, mainly with gunshot wounds, they are scattered throughout the hand - 2.5%, and in 3.6% the localization is not specified. Most surgeons believe that not all foreign bodies should be removed immediately. The only exceptions are graphite, pieces of paint that must be removed because of the danger of tissue necrosis caused by them.

Indications for the removal of a foreign body from the hand, we formulate as follows. Foreign bodies to be removed: 1) visible to the eye and easily palpable; 2) obstructing movement in the joints or interfering with the sliding of the tendons; 3) causing pain, pressing on blood vessels and nerves; 4) supporting inflammation and 5) focusing the attention of the patient.

Timing and technique of surgery are important. Of course, it is most advisable to remove foreign bodies immediately after injury. But this operation can be performed only if the surgeon has the appropriate time and conditions for the intervention, since this operation often turns out to be more difficult than expected. It is difficult to find fragments of the needle in the thickness of the elevation thumb, in the interosseous spaces of the metacarpus, in the canals of the wrist. Many times we ourselves repented of the haste of intervention and received victims from other medical institutions for reoperations when the surgeon or the operating environment was not sufficiently prepared. Therefore, in the order of an emergency operation, only visible and easily palpable foreign bodies are removed.

In other cases, the removal of foreign bodies from the hand is a planned operation that requires preliminary preparation of the patient and the surgeon.

Operation plan: infiltration anesthesia is not recommended, since the injected novocaine displaces tissues. Regional, conduction, intraosseous or intravenous anesthesia or general anesthesia and exsanguination with a Korotkoff cuff should be used. A skin incision is made over the foreign body in a longitudinal or oblique direction, depending on the location. After dissection of the skin and tissue, the edges of the wound are stitched with silk. These "handles" allow you to open the wound and carefully examine it before dissecting the aponeurosis.

Practice shows that with a correctly selected access, a dark dot, or a scar, or infiltrated tissues can be seen on the aponeurosis, indicating the path of entry of a foreign body. We note that several times, when examining the wound with the naked eye, we did not notice these signs. Inspection with a magnifying glass helped to understand. After examining the aponeurosis, the latter is dissected and the tissues are carefully examined again.

So, deepening in layers, the surgeon looks for a foreign body where it was identified during a preliminary study. If it is necessary to pass between the tendon sheaths or muscles, it is necessary to avoid forcible separation of them and dissect the tissues, in accordance with the anatomical relationships.

Sometimes a foreign body can be palpated in the wound with a finger, but the palpation must be carried out very gently and methodically, comparing it with the topographic and anatomical picture of the operated area. Finally, in case of unsuccessful searches, it is important to stop the operation in time, without going beyond the limits of tissue injury, followed by functional disorders. Among our observations there are cases of severe purulent infection after removal of the needle in an unfavorable environment.

Removal of foreign bodies from under the nail. Wooden splinters, pieces of fish bone or needles and other objects get under the nail. Foreign body under the nail causes sharp pain and is often visible to the eye, so the victim (or someone close to him) tries to remove it and breaks off the free end, and only after that he goes to the doctor.

Rice. 141. Foreign body (window bolt) in the proximal interphalangeal joint of the second finger of the left hand.

In such cases, it is recommended to perform a wedge-shaped resection of the nail, release the end of the foreign body enough to capture it with tweezers, and remove it with a smooth movement. After removing the splinter, the wound is smeared with iodine tincture, powdered with streptocide and sealed with collodion. The dressing may be changed infrequently as the nail grows.

Healing of the surgical wound after removal of foreign bodies in 88.9% of patients occurred by primary intention, in 7.5% - by secondary intention, in 3.6% of these cases there is no such information in the case histories. Before the operation of removing a foreign body, a prophylactic dose of 1500 AU of tetanus toxoid is administered. When removing foreign bodies from the hand, there are difficulties not only in finding them, but also in removing them from the tissues. Let's take a look at one of the observations.

At stampers L. the index finger fell under the stamp, and another part of the “window bolt” was driven into the proximal interphalangeal joint of the second finger (Fig. 141). At the health center, they unsuccessfully tried to remove the part, after which the victim was taken to the hospital. She complained of aching pain all over her arm. Operation under anesthesia. The detail had to be knocked out from the rear to the palm with careful blows of a chisel and a chisel. After the part was removed, the epimetaphysis of the middle phalanx was resected, the deep flexor tendon was sutured, fragments of the proximal phalanx were compared, the finger was given a functional position, and the wound was sutured; immobilization of the hand with a back plaster splint. The wounds healed without complications. The finger is in a functionally advantageous position, passively mobile in the interphalangeal joints. Treatment continued for 32 days. Was it worth saving the index finger of the left hand of a 50-year-old worker with a crush injury of the proximal interphalangeal joint and damage to the flexor and extensor tendons of the finger? Three years after the injury, the victim herself answered this question: “My finger works fine, almost no one notices, and I forget that it does not bend on its own.”

The average number of days of disability with foreign bodies of the hand is 9.9.

Removing a ring from a finger

In case of injuries and purulent diseases of the fingers and hand, it may be necessary to remove the ring from the finger. If there is still no reactive edema, then it is enough to raise the patient's hand and hold it in this position for 3-5 minutes, lightly massaging the finger from the distal to the proximal phalanx, then lubricate the skin with vaseline oil, and the ring can be removed with rotational movements.

Rice. 142. Removal of a splinter from under the nail (a); removal of the ring with a thread (b).

The situation is different if the patient has been suffering from pain for several days, the hand and fingers are swollen, the ring has cut into soft tissues, and when you try to advance it, the pain sharply aggravates. The patient demands that the ring be bitten or sawn. This succeeds if the ring is "hollow" or very thin; in most cases, the ring does not bite. You can saw it through if there is a file and a hand vise in the surgical room.

If these tools are not available, then this attempt is unsuccessful, and the patient goes to the jeweler. Meanwhile, the ring is almost always removed with a silk thread. A thick silk thread 50-60 cm long is taken, and one end of it is passed under the ring from the nail to the base of the finger. The long end is tightly wrapped around the finger turn to turn so that not a single millimeter of skin remains that is not entwined with a thread from the ring to the nail. The finger is lubricated with sterile vaseline oil. After that, the end of the thread, brought under the ring, is pulled, folded over the ring, and the thread is slowly unwound. The ring, under the pressure of the proximal edge of the thread sliding along it, moves and gradually slides off (Fig. 142).

E.V.Usoltseva, K.I.Mashkara
Surgery for diseases and injuries of the hand

Even if there were no indications in the anamnesis, the possibility of the presence of a foreign body should never be overlooked - in the case of limited pain, sensitivity, inflammation and impaired function - since it is impossible to explain the disease by other causes.

Needles that have entered the body often cause almost no pain. So, sometimes a piece of a needle is accidentally found in the tissues, the hit of which at one time the patients attach little importance to and about which they completely forgot.

Splinters and needles can easily get into the hands and knees of children crawling on the floor, and with abscesses in these areas, this particular etiology should be suspected.

In cases of suppuration, a foreign body is usually found easily; if it is difficult to judge its location, then it is better to be satisfied for a few days with drainage than to extend the incision to an uninfected area.

Limited soreness to pressure especially clearly locates the foreign body. Taking into account the sensitivity caused by inflammation, if there is a point that is constantly most painful, it directly indicates that a foreign body is located precisely at this place.

By applying pressure with a fingertip or other instrument successively to one place after another of suspicious areas, the surgeon can either find only one painful point or one more painful than the rest of the surrounding areas. Points of the highest, soreness usually correspond to a more superficial part of a foreign body, especially a needle or a sharp piece of glass, wood, etc., and less painful points outline the general direction of the body.

Stereoscopic radiography best of all marks the position and depth of a needle, a piece of glass, etc. If bismuth is rubbed into the skin earlier, then you can very well see the depth of the foreign body from the surface.

You should not proceed with the removal of a foreign body until its position has been precisely determined, if possible. If stereoscopic radiography does not give any indication, simple transillumination can be used, turning the affected organ in different directions until it is possible to determine on the screen how the foreign body lies in relation to the bones.

To determine the location of a bullet, needle or other foreign body in different places on the head, neck, chest, hips, etc., it is possible to combine the indication of stereoscopic radiography with the method of mathematical localization, attaching one or more metal marks to the surface of the skin when translucent.

Found in the tip of the finger, fragments of needles from sewing machines are often stuck, even firmly driven into the bone. When starting to remove such debris, it does not hurt to stock up earlier with a small chisel and mallet, as well as strong tongs.

A fragment of a needle that has fallen into the muscle part of the palm can be significantly displaced in a few hours under the action of muscles that are very close to each other and are constantly in greater or lesser movement. To a much lesser extent, displacement is observed if the needle hits the sole, where the main muscles lie deeper, less compact and where they are less mobile, and the dense plantar fascia delays the foreign body.

Foreign bodies in the palm, according to the direction of the driving violence, are often directed from the palm to the back of the hand and usually to the center of the palm. Those shocks that they experience from the contracting muscles can move them further in the same directions. Most often they pierce into the pulp of the thumb or little finger.

Foreign bodies that have fallen into the foot are usually driven upwards and backwards. There are no abdominal muscles in the heel that could cause them to move forward. It is therefore unlikely that, under the influence of pressure during walking, the latter could be significantly displaced.

When removing small foreign bodies, it does not interfere at all with the following rule: if the foreign body is superficial, then the incision is made in the direction of its axis; if the body lies deeper, then the incision should be made parallel to the fibers lying below the muscles.

Sometimes one end of the needle protrudes under the skin, as soon as the muscles lying under its deeper end contract accordingly. In such cases, it is often possible to push the protruding tip through the skin and remove the needle without any incision.

Unless it is definitely established that the foreign body lies far from the place where it entered, then this place, if it is only known, should be captured in the section for extraction. The entry site of the foreign body must first be marked with a small prick of the skin.

When removing foreign bodies from the fingers, a dissection should be made, if possible, in the gaps formed by the tendons along the midline and the vessels and nerves - on the sides.

Fragments of hard wood that have entered the body, as well as shards of glass, can encapsulate and can often be removed entirely at one end. Splinters from a soft, especially old, tree break off when removed, and, unless the wound is so open that you can see the whole body that has fallen, then even large fragments can go unnoticed in the tissues.

When groping for a needle or other foreign body, the tip of the finger is often much more useful than any probe. It should not be forgotten that the edges of the fascia often give a sensation of a foreign body under the probe. The incision and splitting of these tissues, which deceive your sensation, immediately change the field of operation greatly and violate the main anatomical relationships.

It is highly desirable that when searching for a foreign body, the dissection of tissues should be carried out with systematic and quite distinct cuts.

A little patience, together with accurate localization and careful operative technique, usually lead to successful removal of the foreign body. On the contrary, in the presence of great happiness, the definition is approximate and operations at random lead to disappointment and failure.

When removing foreign bodies from a joint, even fingers dressed in a sterile glove should not be left in the surgical wound longer than necessary.

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Foreign bodies of skin and soft tissues

Often the question arises - to remove or not to remove a foreign body? As a rule, if a little time has passed since the injury and the foreign body is clearly defined, it should be removed. On the other hand, in the absence of symptoms, the risk of surgery to remove it outweighs the risk associated with finding a foreign body, and therefore it is better to leave it in place. In any case, the solution to this sometimes difficult issue depends on the nature of the foreign body and its localization.

The diagnosis is usually made based on the history. However, sometimes the child or parents are not sure if there really was an injury. Plain x-ray does not show all foreign bodies. Significant assistance in the detection of glass, plastic objects and wooden puppies can provide xero (electro) radiography and soft tissue radiography.

A study in transmitted light (transillumination) of small parts of the body, such as fingers, arm, leg, hand, foot, also helps to determine the presence and localization of chips and splinters. In cases where the foreign naked is deep in the muscles or subcutaneous fat, the study must be carried out in two projections, regardless of which method is used.

Unless the foreign body is located quite superficially, then in young children it is most effective and least transmatic to remove it under general anesthesia. In older patients, when manipulating the hand and foot, regional blockade can be used. Local anesthetic infiltration should, however, be avoided because it causes swelling, sometimes slight bleeding, and some tissue displacement, which can complicate an already difficult task.

Small, short pointed objects, such as needles, are especially difficult to remove because they are easily dislodged and migrate into the depths during surgery. It is much easier and more expedient to remove them using general anesthesia and carrying out the intervention under the control of the screen in the operating room. The incision should be small. A clamp is inserted through it, directing it directly to the needle, which is captured and, carefully maneuvering, is removed.

Woody foreign bodies. The tree is almost always contaminated, and therefore, to prevent infection, its pieces that have fallen into the soft tissues must be removed. Around the inlet, soreness and hyperemia of the skin are usually noted. If the sliver is visible, you can use local anesthesia and remove it by grasping it with a clamp or by excising tissue through a small incision directly above it. Deeply located chips or remnants of partially removed foreign bodies should first of all be clearly localized using xero- or soft tissue radiography.

In the presence of multiple small pieces, it is more rational not to search for each, but to excise the wound channel and all affected soft tissues containing foreign bodies, if localization allows this. Splinters under the fingernails or toenails should be removed by wedge-shaped excision of the overlying nail. This converts an anaerobic wound into an aerobic one and, in addition, the entire fragment can be removed without difficulty with this method.

Metal fragments are usually smaller than wood chips and cause a less pronounced reaction. They are especially difficult to detect as they can penetrate deep into soft tissues. Radiography almost always reveals metallic foreign bodies. If they are not clearly defined, then they should not be deleted.

Needles or parts of needles when localized in soft tissues in the palm or foot area can cause serious discomfort. They enter through a small wound and are able to penetrate deeply, migrating with any movement. If a foreign body is detected radiographically, the limb should immediately be immobilized. Successful removal requires general anesthesia, the application of a tourniquet, which allows for bloodless manipulation, and the ability to use an x-ray screen, as described above.

Sometimes in soft tissues remains broken during medical manipulation injection needle - These needles are usually sterile and do not need to be removed urgently, unless removal is difficult or the patient has any symptoms.

If the needle that broke off during the lumbar puncture remained in the region of the spine, then after X-ray control, an operation is performed, which can be not only lengthy, but sometimes even require the removal of the vertebral arch or spinous process.

Fish hooks are usually inserted into the fingers or into the palm of the hand. Their teeth are very difficult to remove. A fishhook can be removed without much difficulty by pushing it forward with a sharp tip, pricking it through the skin and cutting off the prong.

Pieces of glass are often embedded in children in the hand or foot. In some cases, small fragments "splashed" on the face or body can be removed using the Adhesive Patch. Xerorentgenography usually reveals only large pieces of glass in soft tissues. However, they are extremely difficult to detect during surgery. And since they are usually accompanied by minimal inflammation, they are removed later if pain or persistent signs of infection appear.

K.U. Ashcraft, T.M. Holder